According to a blinded, randomized controlled study conducted at 27 hospitals in the United Kingdom and published in the Lancet, a single prophylactic dose of intravenous antibiotics following an operative vaginal birth (by forceps or vacuum extraction) can significantly reduce maternal infection.

Researchers randomly assigned 3,420 women age 16 years or older who had undergone an operative vaginal delivery (at 36 weeks' gestation or later) to two groups: 1,715 received a single intravenous dose of amoxicillin and clavulanic acid within six hours of giving birth, while 1,705 received a placebo (saline) in the same time frame. At six weeks following delivery, women who received antibiotic prophylaxis were less likely to have a confirmed or suspected infection than women who received placebo (11% versus 19%); they also had a 56% decrease in the risk of confirmed systemic infection on culture. Such secondary outcomes as perineal infection, perineal pain, use of pain medication, and wound breakdown were also significantly lower in the prophylaxis group.

While antibiotic prophylaxis for cesarean section is widely recommended on the basis of strong evidence that it significantly reduces maternal infection, the current guidelines of the World Health Organization do not recommend routine administration of prophylactic antibiotics after operative vaginal births because of insufficient evidence of benefit. This study, the researchers assert, provides the grounds to alter practice guidelines. They calculate that for each 100 doses of antibiotics used in prophylaxis, 168 treatment doses would be saved, representing a 17% overall reduction in antibiotic use.

Childbirth experts welcomed the study but with caveats about rushing to change practice guidelines. "This is a great study, but it's just one study," said Jan Kriebs, adjunct professor at the Midwifery Institute at Jefferson University in Philadelphia. "I would be comfortable recommending a single dose of prophylactic antibiotics after operative vaginal delivery. We're balancing a significant reduction of infection risk against a possible increase in antibiotic resistance. However, I would urge the use of informed decision making, where women are informed about the rationale for treatment and the possible risks during consent for care."

Kathleen R. Simpson, editor-in-chief of MCN: The American Journal of Maternal/Child Nursing, also urged careful evaluation. "There may be limited applicability of these findings in the United States, where operative vaginal births represent only about 3% of births," she told AJN, noting that in the study cohort "there were almost twice as many forceps-assisted vaginal births as there were vacuum-assisted vaginal births, which is different than practice in the United States, where vacuum-assisted births are more common than forceps-assisted births."

A spokesperson at the American College of Obstetricians and Gynecologists (ACOG) said in an e-mail to AJN that "ACOG is aware of the study, but at this time there are no changes to recommended clinical practice. We review our guidance on a regular basis and will consider this study, as well as other published literature, as part of our comprehensive review process."-Dalia Sofer

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